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FRACTURE PELVIS

⁕ Introduction :

• The pelvis is a stable rigid ring formed of :

▪ Bones : 2 hip bones , sacrum & coccyx .

▪ Ligaments : mainly anterior & posterior sacro-iliac, sacrospinous ,

sacrotuberous ligments and ligaments related to symphysis pubis .

• The stability of the pelvic ring depends mainly of the posterior arch

(extends backwards & upwards from one acetabulum to the other

acetabulum) (N.B: the anterior arch extends forwards from one
acetabulum to the other acetabulum is weak) .
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⁕ Incidence :

• A rare condition usually suspected with major ( high energy ) trauma

as road traffic accidents .

• Unstable fracture usually associated with other serious injuries &

complications .

• Mortality rate is 5-50% depends on the severity of the fracture and

associated injuries

⁕ Aetiology :

1- Direct trauma : Antero-posterior or lateral compression .

2- Indirect trauma :Vertical shear due vertical directed force as falling

from a hight on the lower limb .

⁕ Classifications: according to

I) Type of trauma :

a-Antero-posterior compression : due to force from front or back .

b- Lateral compression : due to force from the side .

c- Vertical shear : due to vertical directed force .

d- Combined injuries .
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II) Tile’s classification according to stability into :

• Type A :

▪ Stable in rotational & vertical direction because posterior arch is intact.

▪ This type may be one of the followings :

1) A1 : fracture does not involve the pelvic ring as the followings :

 Severe muscular contraction → Avulsion fractures of A.S.I.S,

A.I.I.S., or ischial tuberosity etc.

2) A2 fracture involving the pelvic ring in one site:

 Displacement is slight or absent → no complications.

 This include fracture iliac bone or anterior arch on one side.

1) Type A3 : is transverse sacral fracture .

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• Type B :

▪ Rotationally unstable but vertically stable fracture i.e

partially stable because posterior arch is partially disrupted with
slight displacement .

▪ This type may be one of the followings :

1) B1: is open book fracture ( external rotation ) . There is wide

separation of symphysis pubis and partial disruption of sacroiliac
joint .

2) B2 : is lateral compression fracture ( internal rotation ) . There

are fractures of anterior and posterior arches on the ipsilateral
side .

3) B3 : is fracture lateral compression of anterior arch on one side

and fracture of posterior arch on the contralateral side ( bucket
handle fracture )
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• Type C:

▪ Rotationally but vertically unstable fracture because posterior arch

is completly disrupted .

▪ Displacement is marked upwards by muscles of the trunk and

external rotation by the weight of lower limb ( open book ): → severe
complications and highly fatal.

▪ This type may be one of the followings :

1) C1 :Unilateral injury .

2) C2 :Bilateral injury , type B on one side and type C on the other side

3) C3 : Bilateral injury , type C on both sides or acetabular fracture .

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⁕ Complications: As general rules of fractures especially the followings:

1. Shock , the main cause of death, in unstable fracture is due to injury of

pelvic vessels & severe internal hemorrhage (2-3 liters of blood) , renal
failure and ARDS .

2. Visceral injury may lead to extraperitoneal rupture of bladder,

intrapelvic rupture of urethra, rectum, anus & pelvic vessels .

3. General complications of fractures ( as before in general rules of

fractures )

4. Injury of pelvic nerves especially sciatic nerve injury.

5. Mal-union may lead to perment shortening of L.L.

6. Secondary osteoarthrosis of sacroiliac & hip joints → stiffness.

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⁕ Clinical picture:

1. General exam. and primary assessment of the patient ( ABSDE) .

2. Massive flank or gluteal contusion and swelling are indicative of severe

bleeding .

Manual stress

examination

3. History of severe trauma, pelvic pain & tenderness .

4. The patient can stand in stable fracture and cannot stand in unstable
fracture .

5. Signs of pelvic instability :

• Deformity of lower limb .

• Yielding pelvis by manual stress examination .

• Palpable displacement in the posterior ring ( always exam. the back ).

6. Picture of complications (mention in short).

7. Deformity:

• In unstable fractures, the pelvis is wide and flat (open book deformity).
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• The lower limb is externally rotated due to opening up of the pelvis .

• The lower limb is short due to upwards displacement of the injured

side of the pelvis in vertical unstable fractures .

⁕ Investigations:

1- Plain X-ray : AP , inlet and outlet views .

2- Investigation to detect complications and associated injuries .

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⁕ Treatment:

A. First aid :

1. After any major trauma, fracture pelvis and associated injuries are
suspected .

2. Life threatening problem as airway obstruction , breathing and bleeding

( ABC ) deserve the priority in management .

3. Correct shock & sedatives for pain .

4. Associated injuries usually take priority over the treatment of bone

injuries .

B. Stable fracture :

• Rest in bed with analgesics and physiotherapy.

• After few days the patient start moving out of bed.

C. Unstable fracture :

• Initial stabilization of the fracture by pelvic binder or external pelvic

fixator .

• If after intial stabilization , there is still vascular instability of the

patient , angiography and embolization are performed .

• If all previous measures fails to control bleeding , urgent

exploration , packing of pelvis and surgical haemostasis .

• Finally, treatment of pelvic fracture by open reduction and internal

fixation .
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Pelvic Binder

External skeletal

Fixation for pelvic

fracture

Internal Fixation for

pelvic fracture
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